Medical Review Robin Leigh, R.N., B.S.N.
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1 Medical Review Robin Leigh, R.N., B.S.N.
2 Medical Review The List Going Beyond The List It s not what we do, it s why we do it Accuracy of Problem Identification Efficiency of Review Process Efficiency of Edit Effectiveness Additional Documentation Requests (ADR) FAQs
3 Medical Review Strategy The List Part A Inpatient Services: Two-Day Stays for Heart Failure and Shock with MCC DRG 291 Two-Day Stays for Heart Failure and Shock with CC DRG 292 Two-Day Stays for Heart Failure and Shock without MCC/CC DRG 293 Two-Day Stays for Cardiac Arrhythmia with MCC DRG 308 Two-Day Stays for Cardiac Arrhythmia with CC DRG 309 Two-Day Stays for Esophagitis Gastroenteritis with MCC DRG 391 Two-Day Stays for Esophagitis Gastroenteritis without MCC DRG 392 Two-Day Stays for Nutritional and Metabolic Disorders with MCC DRG 640 Two-Day Stays for Nutritional and Metabolic Disorders without MCC DRG 641 Two-Day Stays for Kidney and Urinary Tract Infections with MCC DRG 689 Two-Day Stays for Kidney and Urinary Tract Infections without MCC DRG 690 One-Day Stays for Atherosclerosis with MCC DRG 302 One-Day Stays for Atherosclerosis without MCC DRG 303 One-Day Stays for Chest Pain DRG 313 Cardiac Valve and Other Major Cardiothoracic Procedure Range DRG Spinal Fusion except Cervical with MCC DRG 459 Spinal Fusion except Cervical without MCC DRG 460 Skilled Nursing Facility Service: SNF RUG ES330 SNF RUG RUC30 Lower RUG SNF Beneficiary Edit Inpatient Rehabilitation Facility Service: Tier A Case Mix Group (CMG) Stroke Codes A0101 A0110 Ambulance: Ambulance Service, Conventional Air Services, Transport, One Way (Rotary Wing): A0431/A0436 The List Part B Evaluation and Management Surgical Debridement CPT codes
4 Medical Review Strategy Going Beyond the List It s not what we do, it s why we do it Educational focus Reduction of the National Claims Payment Error Rate
5 Medical Review Strategy Accuracy of Problem Identification Improved data analysis Strong collaboration between the statisticians and clinicians As compared to a year ago, we are three times better at identifying problem areas
6 Medical Review Strategy Efficiency of Review Process Inpatient Increase by 329% Pulmonary Rehab Increase by 70% SNF Increase by 35% E/M Increase by 9% Overall improvement in our internal quality scores Inter-Reviewer Reliability Individual Quality Assessment
7 Medical Review Strategy Efficiency of Edit Effectiveness Period of time from when we start requesting records until the results are sent to the provider Period of time from the date the last claim in the probe is reviewed until the results are sent to the provider
8 Additional Documentation Request (ADR) Reminders: Include barcoded ADR letter as the first page of the documentation for each separate claim Respond within 30 days, as the claim will automatically deny for no response on day 45 Do not use staples If sending a password protected CD be sure to send the tracking number and password to Dan.Grassi@PalmettoGBA.comor Lisa.Cooper@PalmettoGBA.com You are encouraged to send MR ADR responses electronically via esmd. Additional info at
9 Additional Documentation Request (ADR) -esmd Additional info at
10 MR FAQs Question: We are submitting the same documentation to multiple CMS contractors, is there a way to share the records to prevent duplicative production of the records? Response: Once a record has been selected for review, another CMS contractor should not be requesting documentation for the same claim.
11 MR FAQs Question: I receive a denial from MR for missing cardiac components, then when I submit a redetermination with the cardiac components my appeal is upheld because the order was missing. Help! Response: In September 2013, Medical Review began performing an end to end review and citing all reasons for denial.
12 MR FAQs Question: Is InterQual used as a definitive tool to determine payment? Response: InterQual is one tool that we use when reviewing claims, however it does not lead us to a definitive answer.
13 MR FAQs Question: I heard that the timeframe to submit our response to CERT documentation requests was changing from 75 to 60 days. Is that accurate? Response: CMS had planned to change the timeframe effective 1/1/14, however CMS has decided to leave it at 75 days.
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